Physical Therapy (CPB 0325, reviewed 2026-06-02)

By June 2, 2026: (1) Billing and authorization teams must update claim denial rules to reject any PT claims using experimental modalities listed in the policy (kinesio taping, blood flow restriction therapy, dynamic movement intervention, MEDEK therapy, virtual reality gait training, hivamat therapy, low-dye strapping for stress fractures, ultrasound for Dupuytren's contracture, applied functional science, adhesion removal PT, and others). (2) Update prior authorization templates to require documentation showing: (a) specific condition with reasonable expectation of significant improvement within one month of therapy start, OR (b) necessity for establishing a safe home maintenance program. (3) Ensure all PT claims submitted include written plan of care with objective/subjective data per Appendix A requirements—claims lacking documentation will be denied. (4) Verify PT provider licensure and scope of practice in their jurisdiction; reject claims from unlicensed providers or those outside permitted scope. (5) Audit active PT authorizations for members with non-improving or static conditions; deny continued coverage once therapeutic benefit achieved or home exercise program is viable. (6) For hand-held soft tissue mobilization tools (e.g., ThermoStim probe): process as standard myofascial release without additional reimbursement for device; approve electrical stimulation modality if applicable. (7) For members receiving home-based PT: verify medical necessity is documented for functional performance needs in home environment or transition to maintenance program. (8) For HMO/QPOS/Health Network plans: enforce 60-day rehabilitation benefit limits and ensure PT courses for separate conditions are tracked separately. Billing and clinical authorization staff must review and implement these changes; failure to comply will result in claim denials and potential overpayment recovery.